Better Nights, Better Days What, Why & How · An actigraph is a wrist-watch like device with an...
Transcript of Better Nights, Better Days What, Why & How · An actigraph is a wrist-watch like device with an...
Better Nights, Better Days –
What, Why & How
Penny Corkum, PhD (Psychologist)
Professor, Department of Psychology & Neuroscience, & Psychiatry,
Dalhousie University
Scientific Staff, IWK Health Centre
Director, Colchester East Hants ADHD Clinic
92nd Annual Dalhousie Fall RefresherDecember 6-8, 2019 │Halifax, NS
• I have no actual or potential conflict of interest in relation to
this presentation
• Research funding from Canadian Institutes of Health Research,
Kids Brain Health Network (a National Center of Excellence),
Nova Scotia Health Research Foundation, IWK Health Centre,
& Dalhousie’s Psychiatry Research Foundation
Educational Objectives
At the end of this session,
participants will be able to:◦ Have increased knowledge about
the prevalence and impact of sleep
problems, particularly pediatric
insomnia
◦ Understand best practice to
treatment of pediatric insomnia
and barriers to the provision of
this care
◦ Become familiar with the Better
Nights, Better Days programs and
future plans for sustainability of
these program
Session Overview
Refresher re: sleep
structure
Sleep disorders
Insomnia – contributing
factors and consequences
Assessment
Treatment
Questions & Answers
10-year-old boy
Only child
Parents divorced; Alex lives mostly with mom but stays at his dad’s house every second weekend
Bedtime 9:30pm; Wake time: 6:30am
Trouble falling asleep (60-120min)
Once asleep stays asleep (used to have night awakenings)
Trouble waking up in morning, results in lots of stress
Parents and teachers think that at times Alex seems tired and other times he seems revved up
Has ongoing academic problems, attention problems and at times he’s irritable
▪ REM (20-25% of total sleep; 4-6 episodes)
▪ High levels of cortical activity
▪ Paralysis
▪ Episodic bursts of eye movements
▪ Occurs 70-100 min after sleep onset
▪ Function
▪ Learning, memory consolidation
▪ NREM (75-80% of
total sleep)
▪ 3 stages (previously
considered 4 stages)
▪ Low brain activity
▪ Body movements are
preserved
▪ Function
▪ Restoration of body
functions
▪ NREM/REM alternate through the night in cycles
▪ Cycles of about 90-100 minutes
▪ Brief arousal and return to sleep every cycle (4-6 times)
▪ Early sleep mostly NREM, later sleep mostly REM
http://sleepfoundation.org/how-sleep-
works/how-much-sleep-do-we-really-need
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https://www.participaction.com/en-ca
0-3 months: 14-17 hours
4-11 months: 12-16 hours
1-2 years: 11-14 hours
3-4 years: 10-13 hours
5-13 years: 9-11 hours
14-17 years: 8-10 hours
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• Children’s sleep duration has decreased between 30 minutes to one hour in recent decades
• 31% of school-aged children and 26% of adolescents in Canada are sleep-deprived
• 36% of Canadian 14-17 year olds find it difficult to stay awake during the day
• 43% of Canadian 16-17 year olds are not getting enough sleep on weekdays
• 33% of 5-13 year olds and 45% of 14-17 year-olds in Canada have trouble going to sleep or staying asleep at least some of the time
• Sleep is an essential component of healthy cognitive and physical development
• …because many kids are too tired to get enough physical activity during the day, and not active enough to be tired at night – it’s a vicious cycle.
DSM-5 (2013) / ICSD-3 (2013)
◦ 10 different sleep disorders/sleep disorder groupings
1) Insomnia Disorder
2) Hypersomnolence Disorder
3) Narcolepsy
4) Breathing-related sleep disorders
5) Circadian rhythm sleep-wake disorders
6) Non–rapid eye movement (NREM) sleep arousal disorders
7) Nightmare disorder
8) Rapid eye movement (REM) sleep behavior disorder
9) Restless legs syndrome
10) Substance/medication-induced sleep disorder
Maski, K., & Owens, J. (2018). Pediatric sleep disorders. CONTINUUM: Lifelong Learning in Neurology, 24(1), 210–227.
Kotagal, S. (2017). Sleep-wake disorders of childhood. CONTINUUM: Lifelong Learning in Neurology, 23(4), 1132–1150.
Disorder Prevalence
Narcolepsy .05%
Restless Leg Syndrome/PLMD 2-6%
Sleep Disordered Breathing 2-3%
Circadian rhythm disorders 7%
Parasomnias
NREM
REM
13%
5%
Insomnia 20-30%*
American Academy of Sleep Medicine. International classification of sleep disorders
(ICSD). 3rd ed; 2014. Available in:http://www.aasmnet.org/library/default.aspx?id=9
* 70%+ for children with NDDs
Criteria (ICSD-3 & DSM-5)
◦ Difficulties falling asleep/difficulty initiating sleep without parent/caregiver intervention, staying asleep, and early waking (resistance to going to bed; ICSD-3 only)
◦ Impairment/Daytime consequences of sleep problem (e.g., daytime sleepiness, attention problems, mood disturbance/ irritability, behaviour problems, low motivation/energy/initiative)
◦ Sleep problem cannot be explained by inadequate opportunity for sleeping
◦ Frequent (≥3x/wk) and chronic (≥3 mos)
◦ Not explained by or occur exclusively during another sleep-wake disorder, medical condition, or mental health disorder
Children
◦ sleep-onset association
◦ limit-setting
Adolescents
◦ sleep hygiene problems
◦ delayed sleep phase
Young Adult
◦ psychophysiological insomnia
Developmental Stage Prevalence
Infants/Toddlers ~30%
Preschoolers/School-aged ~15%
Adolescents (peak at puberty) ~30%
Adult ~15%
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Sleep
Genetics
Sleep Environ-
ment
Family/ Parents
Health
Develop-ment
Social –Emotional
Social –Cultural
Sleep Practices
Slide courtesy of Jodi Mindell
3 “P”s:
Predisposing
Precipitating
Perpetuating
Cognition/
LearningMental Health
Physical
Health
Quality of
Life
Community
School
Family
Child
Consequences of Sleep
Problems/Disorders
Interviews &
QuestionnairesSleep Diary Actigraphy PSG
Subjective Objective
SCREENING
▪Ask about sleep!
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Owens, JA. & Dalzell, V. (2005). Use of the ‘BEARS’ sleep screening tool in a pediatric resident’s continuity clinic: A pilot study. Sleep Medicine, 6 (1), 63-9.
Lewandowski et al., 2011
◦ Review of Pediatric Questionnaires (n=21)
◦ Multidimensional sleep measures received the highest ratings
◦ 6 “Well Established” Brief Infant Sleep Questionnaire (Sadeh, 2004) (0-29 months)
Infant Sleep Questionnaire (Morell, 1999) (12-18 months)
Child Sleep Habits Questionnaire (Owens et al., 2005) (2.5-10 years)
Preschool Sleep Questionnaire (Chervin, 1997) (2-18 years)
Sleep Disturbances Scale for Children (Bruni, 1996) (5-15 years)
Pediatric Daytime Sleepiness Scale (Drake et al., 2003) (11-15 yrs)
Ji & Liu, 2016
◦ Review of Adolescent Questionnaires (n=13)
◦ Most validated questionnaires Cleveland Adolescent Sleepiness Questionnaire (Spilsbury et al., 2007) (11-17yrs)
Chronic Sleep Reduction Questionnaire (Dewald et al. 2012; Meijer, 2008) (12-16.5 yrs)
Lewandowski, A. S., Toliver-Sokol, M., & Palermo, T. M. (2011). Evidence-based review of subjective pediatric
sleep measures. Journal Of Pediatric Psychology, 36(7), 780-793. doi:10.1093/jpepsy/jsq119
Ji, X. & Liu, J. (2016). Subjective sleep measures for adolescents: a systematic review. Child: care, health and
development, 42, 6, 825–839
Total Sleep Disturbances
(Cutoff=41)
Bedtime Resistance
Sleep Onset Delay
Sleep Duration
Sleep Anxiety
Night Wakings
Para-somnias
Sleep Disordered Breathing
Daytime Sleepiness
Owens, JA., Spirito, A., & McGuinn, M. (2000). The Children’s Sleep Habits Questionnaire (CSHQ):
Psychometric properties of a survey instrument for school-aged children. Sleep, 23(8), 1-9.
45 Items
• Record of sleep and wake times and related information
• Completed by parent and/or child
• Commonly used in clinical practice
• Examines for patterns across days/weeks
http://www.sleepforkids.org/pdf/SleepDiary.pdf
http://www.sleepforkids.org/index.html
Corkum, et al. (unpublished)
• An actigraph is a wrist-watch like device with an accelerometer used to measure movement.
• Computer algorithms are used to interpret accelerometer-based findings as measures of sleep and waking.
• Actigraphy has become an increasingly popular method for estimating sleep parameters in both research and clinical studies over the past 30 years.
Considered the gold standard for measuring sleep
Measures:◦ Brain waves/activity
◦ Oxygen level
◦ Breathing
◦ Heart rate
◦ Eye and leg movements
10-year-old boy
Only child
Parents divorced; Alex lives mostly with mom but stays at his dad’s house every second weekend
Bedtime 9:30pm; Wake time: 6:30am
Trouble falling asleep (60-120min)
Once asleep stays asleep (used to have night awakenings)
Trouble waking up in morning, results in lots of stress
Parents and teachers think that at times Alex seems tired and other times he seems revved up
Has ongoing academic problems, attention problems and at times he’s irritable
What diagnosis do you think
is most likely?
What assessment approach
would you take to determine
his diagnosis?
What additional information
would you want?
Best Practice Treatment
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Psycho-education
Healthy Sleep Practices
Behavioural Strategies
MedicationLess than 15% of children
with insomnia receive
evidence-based treatment
Sometimes sleep problems are a result of lack of knowledge and due to faulty beliefs, for example…◦ Expect the child to sleep too long/too little
◦ Lack of understanding of circadian rhythms and sleep pressure
◦ Expect child to have same chronotype as parents (e.g., owl/lark)
◦ Think that keeping child up later will result in the child sleeping in later in the morning
◦ Think that arousals at night are not typical (rather than seeing this as self-soothing problem)
◦ Not understanding the biological shift in sleep time during adolescents
Handouts for parents
◦ Mindell, J. A., & Owens, J. A. (2010). A clinical guide to pediatric sleep: Diagnosis and management
of sleep problems (1st ed.). Baltimore, MD: Lippincott Williams & Wilkins
Resource List
◦ Corkum LABS
Websites◦ Canadian Sleep Society
Brochure and eBook - https://css-scs.ca/resources/brochures
Insomnia Rounds - https://css-scs.ca/resources/insomnia
◦ Pediatric Sleep Council
https://www.babysleep.com/
◦ Sleep for Kids
http://sleepforkids.org/
◦ Participaction
https://www.participaction.com/
◦ National Sleep Foundation
https://www.sleepfoundation.org/
https://www.sleep.org/
◦ Better Nights, Better Days www.betternightsbetterdays.ca
www.facebook.com/betternightsdays
Age-appropriate
Bedtimes, wake-times and naps, with
Consistency
Schedule and routines
Location
no Electronics in the bedroom or before bed
Exercise and diet
Positivity and relaxation
Independence when falling asleep
Needs met during the day
….all of the above equals Great sleep!
Bessey, J. Coulombe, A. & Corkum, P. (2013). Sleep Hygiene in Children with ADHD: Research Findings and Clinical
Recommendations. ADHD Report, 21 (3).
Allen, S., Howlett, M., Coulombe, A., & Corkum, P. (2015). ABCs of Sleeping: A Review of the Evidence Behind
Pediatric Sleep Practice Recommendations. Sleep Medicine Reviews.
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Step 1: Online Questionnaire
Step 2: Report Card
Step 3: Handouts
If you are interested in
participating, please
contact us at
Vriend, J. & Corkum, P. (2011). Clinical management of behavioral insomnia of
childhood. Psychology Research and Behavior Management. 4, 69-79. Doi:
http://dx.doi.org/10.2147/PRBM.S14057
Corkum, P., Davidson, F., Tan-MacNeill, K., & Weiss, S. (2014). Sleep in Children with
Neurodevelopmental Disorders: A focus on insomnia in children with AD/HD and ASD.
Sleep Medicine Clinics. 9(2), 149-168. Doi: 10.1016/j.jsmc.2014.02.006
Goal typically involves some combination of developing positive
sleep-related associations, establishing routines, and
implementing relaxation/self-soothing skills
Strong evidence for sleep intervention programs- with TD
◦ 94% of studies found behavioural interventions to be effective
◦ 80% of children had clinically significant improvements
◦ Improvements in sleep onset latency, frequency and duration of night
wakings and sleep efficiency (not sleep duration)
◦ Improvements lasted 3 to 6 months
◦ Few studies on children with special needs
Learning
Principles
Unmodified
Extinction
Extinction
with parent
presence
Graduated
Extinction
Bedtime
Fading
Stimulus
control
Sleep
Scheduling
Sleep
restriction
Cognitive
Strategies
Relaxation
Training
Reward
Programs
Specific Sleep Strategies
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Intervention Description
Unmodified Extinction Infant is placed in bed while awake, left alone until asleep, and night-wakings are ignored. Infant learns to
self-soothe once realizing that nighttime crying does not result in parental attention.
Extinction with parent
presence
Parent remains in room during extinction, acting as a reassurance for the child but providing little
interaction.
Graduate Extinction This involves ignoring negative behaviors (i.e., crying) for a given amount of time before checking on the
child. The parent gradually increases the amount of time between crying and parental response. Parents
provide reassurance through their presence for short durations and with minimal interaction.
Bedtime Fading Operates by delaying bedtime closer to the child’s target bedtime. The goal of this treatment is for the child
to develop a positive association between being in bed and falling asleep rapidly. Bedtimes can be gradually
moved earlier.
Stimulus Control Making the bedroom/bed a discriminant stimulus for sleep by only using the bedroom/bed for sleep (not
play, time-outs, etc.)
Sleep Scheduling Scheduling regular, appropriate sleep and wake times that allow for an adequate sleep opportunity.
Sleep Restriction Restrict time in bed to build sleep pressure and gradually lengthen time in bed as sleep efficiency improves.
Contraindicated in youth with parasomnias, seizure disorders, OSA, mania
Cognitive Strategies These strategies are used to address non-productive beliefs about sleep, including the belief that the child
cannot change their sleep difficulty. Coping strategies are also included (e.g., relaxation skills such as
abdominal breathing).
Relaxation Training Teach diaphragmatic (belly) breathing and progressive muscle relation to reduce arousal. Need to practice
regularly before introducing at bedtime.
Reward Programs Reinforce healthy sleep practices, appropriate time in bed, etc.
GREAT SLEEP CHART
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0 – 19 No reward20 – 39 $5 gift certificate from Blockbuster or Empire Theatres40 – 59 $10 gift certificate from Blockbuster or Empire Theatres60 – 70 $20 gift certificate from Blockbuster or Empire Theatres
Community Mental Health
◦ https://novascotia.ca/dhw/mental-health/children-and-
youth.asp
Private Practice Psychologist
◦ http://apns.ca/search-psychologist/
Canadian Sleep Society Service Providers Map
◦ https://css-scs.ca/resources/provider-map
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http://betternightsbetterdays.ca/http://ndd.betternightsbetterdays.ca/
42Better Nights, Better Days
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http://betternightsbetterdays.ca/
http://ndd.betternightsbetterdays.ca/
Better Nights, Better Days
www.ndd.betternightsbetterdays.ca
www.facebook.com/betternightsdays
https://twitter.com/betternightsday
https://www.instagram.com/betternightsbetterdays/
https://www.pinterest.com/betternightsbet/
[email protected] Adolescents: 14-18 yearsYoung Adults: 19-24 years
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Children presenting with insomnia are being prescribed
medication at high rates, especially when child has a NDD
(Stojanovski et al., 2007; Owens et al., 2010)
◦ e.g., antidepressants, atypical antipsychotics, anticonvulsants,
beta-blockers
No FDA approved medications for treatment of insomnia in
children and there are concerns about the safety and side effects
of these medications (Owens et al., 2010)
Pharmacological treatments may have rapid short-term effects
on sleep problems, but typically do not have long-term positive
effects on sleep
Nunes, N.L. & Bruni, O. (2015). Insomnia in childhood and adolescence: clinical aspects,
diagnosis, and therapeutic approach. J Pediatr (Rio J). 2015;91(6 Suppl 1):S26---S35
Pelayo, R., & Yuen, K. (2012). Pediatric Sleep Pharmacology. Child Adolesc Psychiatric Clin N
Am 21, 861–883
Troester,M.M. & Pelayo, R. (2015). Pediatric Sleep Pharmacology: A Primer. Semin Pediatr
Neurol, 22,135-147
https://choosingwiselycanada.org/
Melatonin
• Melatonin is secreted by the pineal gland in response to darkness and is involved in maintaining the circadian rhythm of the sleep-wake cycle
• Melatonin supplements provide much larger amount than what is typically secreted
• Studies that exist find benefit and few side-effects• Short-acting forms used to treat sleep onset problems and
long acting forms to treat sleep maintained problems• However, studies include small sample sizes and do not assess
long-term use• Canadian Pediatric Society Position Paper re: Melatonin
◦ http://www.cps.ca/documents/position/melatonin-sleep-disorderschildren-adolescents
• First step in management of all sleep disorders is
establishing good sleep hygiene
• All studies have involved small numbers of subjects and
address only short-term use
• No good data concerning the safety and efficacy of long-
term melatnoin use
• Further studies are needed to confirm the usefulness and
safety of melatonin for sleep disorders in children and
adolescents2012, Reaffirmed 2015
10-year-old boy
Only child
Parents divorced; Alex lives mostly with mom but stays at his dad’s house every second weekend
Bedtime 9:30pm; Wake time: 6:30am
Trouble falling asleep (60-120min)
Once asleep stays asleep (used to have night awakenings)
Trouble waking up in morning, results in lots of stress
Parents and teachers think that at times Alex seems tired and other times he seems revved up
Has ongoing academic problems, attention problems and at times he’s irritable
What treatment plan would
you suggest for Alex?
How would you change your
treatment approach in these
situations?• Alex has ADHD and is on stimulant
medication?
• Alex has ASD and an anxiety
disorder?
Resources
Durand VM. When Children Don’t Sleep Well: Therapist Guide: Interventions for Pediatric Sleep Disorders (Treatments that work). New York: Oxford University Press; 2008.
Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
Sheldon SS, Ferber R, Kryger MH. Principles and Practice of Pediatric Sleep Medicine. 1st ed. Philadelphia, PA: W.B. Saunders; 2005.
Stores G, Wiggs L. Sleep Disturbance in Children and Adolescents with Disorders of Development: Its Significance and Management. London, UK: MacKeith Press; 2001.
Autism Speaks Sleep Tool Kit◦ https://www.autismspeaks.org/science/res
ources-programs/autism-treatment-network/tools-you-can-use/sleep-tool-kit
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http://myweb.dal.ca/pvcorkum/